The pharmaceutical and medical device industries fund a substantial portion of the continuing medical education (CME) of physicians in Canada. Along with this financial support come avenues for industry influence.1,2 Continuing medical education organizers are often under overt pressure to design sessions and choose faculty3 to attract industry funding. Organizers might also be affected by more subtle tactics. Research in social science demonstrates that the recipient of a gift feels a sense of obligation that is often subconscious.4

This might cause CME organizers to respond in predictable and accommodating ways to sponsorship from industry. The conflicts of interest CME faculty (organizers and speakers) have with industry likely also have an effect on CME content.5 Whatever the mechanism, CME with industry involvement has a narrower range of topics and more drug-related content than CME without direct industry involvement.6 Even when funding is unrestricted (course content and faculty are determined by the program director, not industry), the content favours the sponsor’s product.7

Few dispute that the bias introduced by industry involvement in CME affects physician prescribing.8 And, as stated by the US Senate Finance Committee in 2007, “it seems unlikely that this sophisticated industry would spend such large sums on an enterprise but for the expectation that the expenditures will be recouped by increased sales.”9 The real question is whether industry’s influence is harmful. Most agree that industry’s primary objective of increasing sales10 creates an inherent tension with the physician’s goal of getting the best medical information.

Some physicians have argued that despite this conflict, they can still accept the benefits of industry funding; they have the ability to accurately detect bias and distil out truth. However, studies contradict this. Physicians who interact more often with industry have poorer prescribing habits and are less likely to follow guidelines.11 Some of the most damning evidence of harm comes from a retrospective analysis of the “OxyContin crisis” by Van Zee.12 The analysis clearly demonstrates how industry influence over physician prescribing can have devastating outcomes. In 1996, Purdue’s launch of OxyContin involved the creation of a speakers’ bureau with thousands of physicians and, between 1996 and 2002, the sponsorship of more than 20 000 educational programs. The educational sessions were driven and funded by the pharmaceutical company, led by industry-sponsored physicians, and accredited by professional bodies. Purdue achieved unprecedented success. In the United States, OxyContin sales grew from $48 million (US) in 1996 to almost $1.1 billion (US) in 2000. However, the educational information Purdue disseminated on OxyContin misrepresented the risk of addiction and abuse.13–15 The unprecedented success was accompanied by an epidemic of OxyContin-related harms. Unfortunately, the OxyContin “commercial triumph, public health tragedy” story is not unique; there are many other reports of poor patient outcomes as a result of industry involvement in CME in other drug classes.16

As a result, many are calling for a ban on industry sponsorship of CME and a divestment of conflicts of interest from CME faculty.17 To move forward with these changes, academic centres and professional medical associations (PMAs) are looking to their physician members for support and direction. Unfortunately, it might be difficult for physicians to see how their interactions with industry can adversely influence them. When researchers presented physicians with proposed conflict-of-interest regulations that would apply to them, they were much more resistant than when the identical scenario referred to financial planners. Financial planners showed the same self-interest in this study; they were more likely to oppose conflict-of-interest regulations when the scenario referred to financial planners than when it referred to physicians.18 Studies on decision making from the social science field indicate that this self-interest is unintentional and unconscious. Even when individuals are instructed about self-serving bias and are motivated to remain objective, they are unable to do so.19

Where we are in Canada

Ongoing medical education is clearly essential for physicians. However, unlike for undergraduate and postgraduate medical education, there are no streams of revenue for CME in Canada. Industry, with a fistful of money, has eagerly stepped into this void. At present, industry funds accredited CME in Canada and contributes to organizations that produce CME programs for hospitals, PMAs, and universities. Financial conflicts of interest with industry are likely prevalent among Canadian CME faculty as well.20

Industry is also involved in CME development in Canada. The Royal College of Physicians and Surgeons of Canada (RCPSC) permits industry to co-develop CME with the physician organization, but prohibits industry representatives from sitting on scientific planning committees.21 The College of Family Physicians of Canada (CFPC) has recently changed its policy; its 2012 fall continuing professional development newsletter stated that, starting in January 2013, industry would not be permitted to attend CME content planning meetings nor be allowed to “have any role” in CME program content development.22 The current CFPC guidelines reflect this statement.23 University policies adhere to the guidelines from the colleges and allow industry involvement in CME development but prohibit industry representatives from sitting on the scientific planning committees. University policies also permit industry to direct unrestricted funds to specific CME events.24–26

What should be done

Industry involvement in CME

Ideally, Canadian academic centres, hospitals, and PMAs should ban all industry involvement (including funding) in CME. Several American institutions have taken this route with success, including the University of Michigan, the Memorial Sloan Kettering Cancer Center, the Brody School of Medicine at East Carolina University, the Kaiser Permanente in the Mid-Atlantic States region, and the Oregon Academy of Family Physicians.27,28

At a minimum, Canadian organizations should do what some American institutions have done and only allow industry to contribute unrestricted funding to a central pool within the larger organization.29 An independent medical body disperses the pool of money to pay for CME events. Industry is not allowed to participate in the planning, development, or delivery of CME. Although many find this “firewall” approach appealing (and one study found it to be effective6), it might still engender subconscious reciprocity.4 As well, organizations could feel pressure to adopt industry-friendly policies and programs to attract funding.9

The CFPC and the RCPSC should implement a 5-year plan to only accredit CME programs that do not have funding from industry. As a first step, the colleges should prohibit industry involvement in the planning, development, and delivery of CME, not just the educational component. They should explicitly state in their guidelines that industry is not permitted to suggest speakers or content to the planning committee.

Faculty conflicts of interest

The simplest solution is to prohibit physicians with financial conflicts of interest from planning or teaching CME. The US Accreditation Council on Continuing Medical Education did recommend this in 2003. However, the proposal died early on, as many believed this would “empty lecterns and podia across the continent,”30 and regulators continued to focus on transparency. Unfortunately, disclosure has substantial limitations and might increase bias,31–33 so divestment is back in the spotlight. Some American institutions have moved forward on this; 44 medical schools now “ban or severely restrict” faculty participation in speaker bureaus.34 Harvard University has set financial limits for conflicts of interest for its faculty.35 Many schools also limit and regulate faculty consulting relationships with industry. Canadian academic institutions, hospitals, and PMAs should follow the lead of these institutions and ban faculty from participating in speaker bureaus. They should also set financial limits on faculty conflicts of interest and regulate consulting relationships. The CFPC and the RCPSC should develop 5-year plans to only accredit CME programs that have faculty without personal income from industry.36 A goal of zero payments is important because even a small financial payoff can distort a recipient’s judgment.19 They should also develop a policy to address financial conflicts of interest that fall outside personal payments from industry, such as industry funding of a physician’s research. And finally, they need a policy to address non-financial conflicts of interest (personal, political, ideological, religious, etc) for CME faculty.37

Maintaining CME without industry support

Physicians frequently express concern that we will not be able to maintain the quality and quantity of CME without industry support. To address this, some have suggested “rethinking continuing medical education.”38 The large conferences at expensive venues are a poor way to deliver CME. The most effective (and more cost-effective) CME is held in small groups, with practice audits, ongoing support, and follow-up. Organizations could further reduce costs by offering CME in local community hospitals and clinics or online. As well, professional associations, such as the CFPC, could develop educational objectives or a standard curriculum. Currently, the development of CME is haphazard and is often determined by industry funding. Implementing these suggestions would lead to higher-quality CME and cost savings. Second, programs will have to find alternative sources of funding. Physicians could pay more in fees. The pharmaceutical and medical device industry could pay a CME tax. For instance, France levies a 1.6% tax on industry to fund CME programs.39

The public health care system could cover more costs. At present, the public already pays the higher drug costs passed on from industry sponsorship of CME. Public funding of CME might eventually lead to drug cost savings for the public. With the loss of industry influence, doctors will begin to prescribe more appropriately. They will eschew more expensive “me-too” drugs in favour of the cheaper, older medications with proven outcomes and established safety profiles.

Conclusion

The involvement of the pharmaceutical and medical device industries in the provision of CME has a harmful influence on physician prescribing practices. Current measures to limit industry’s influence are inadequate. Academic centres, hospitals, and PMAs need to demonstrate leadership. They should start by limiting industry involvement in CME and restricting faculty conflicts of interest. The RCPSC and the CFPC should develop a 5-year plan to only accredit CME with no industry funding and with faculty with no conflicts of interest. Continuing medical education can be funded through alternative means such as physician payments and public funding. Overall CME costs can be reduced, and delivery improved, with a change in the way CME is approached. Ultimately, limits on industry involvement will improve physician prescribing and patient outcomes, at a lower cost to the public.